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Khan A, Frazer-Green L, Amin R, Wolfe L, Faulkner G, Casey K, Sharma G, Selim B, Zielinski D, Aboussouan LS, McKim D, Gay P. Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report. Chest 2023; 164:394-413. [PMID: 36921894 DOI: 10.1016/j.chest.2023.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations. STUDY DESIGN AND METHODS An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations. RESULTS Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement. INTERPRETATION Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making.
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Affiliation(s)
- Akram Khan
- Division of Pulmonary Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR.
| | | | - Reshma Amin
- Department of Respiratory Medicine, The Hospital for Sick Kids, Toronto
| | - Lisa Wolfe
- Department of Medicine, Northwestern University, Chicago, IL
| | | | - Kenneth Casey
- Department of Sleep Medicine, William S. Middleton Memorial Veterans Hospital, Shorewood Hills, WI
| | - Girish Sharma
- Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Bernardo Selim
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Zielinski
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | | | - Douglas McKim
- Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, ON
| | - Peter Gay
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
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Tabor Gray L, Donohue C, Vasilopoulos T, Wymer JP, Plowman EK. Maximum Phonation Time as a Surrogate Marker for Airway Clearance Physiologic Capacity and Pulmonary Function in Individuals With Amyotrophic Lateral Sclerosis. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2023; 66:1165-1172. [PMID: 36877985 PMCID: PMC10187964 DOI: 10.1044/2022_jslhr-22-00522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/23/2022] [Accepted: 12/12/2022] [Indexed: 05/18/2023]
Abstract
PURPOSE The increased use of telehealth practices has created a critical need for home-based surrogate markers for prognostic respiratory indicators of disease progression in persons with amyotrophic lateral sclerosis (pALS). Given that phonation relies on the respiratory subsystem of speech production, we aimed to examine the relationships between maximum phonation time (MPT), forced vital capacity, and peak cough flow and to determine the discriminant ability of MPT to detect forced vital capacity and peak cough flow impairments in pALS. METHOD MPT, peak cough flow, forced vital capacity, and ALS Functional Rating Scale scores were obtained from 62 pALS (El-Escorial Revised) every 3 months as part of a longitudinal natural history study. Pearson's correlations, linear regressions, and receiver operator characteristic curve analyses with the area under the curve (AUC), sensitivity, specificity, and likelihood ratios were calculated. RESULTS The mean age of pALS was 63.14 ± 10.95 years, 49% were female, and 43% had bulbar onset. MPT predicted forced vital capacity, F(1, 225) = 117.96, p < .0001, and peak cough flow, F(1, 217) = 98.79, p < .0001. A significant interaction was noted between MPT and ALS Functional Rating Scale-Revised respiratory subscore for forced vital capacity, F(1, 222) = 6.7, p = .010, and peak cough flow, F(1, 215) = 4.37, p = .034. The discriminant ability of MPT was excellent for peak cough flow (AUC = 0.88) and acceptable for forced vital capacity (AUC = 0.78). CONCLUSIONS MPT is a simple clinical test that can be measured via telehealth and represents a potential surrogate marker for important respiratory and airway clearance indices. Further larger studies are required to validate these findings with remote data collection. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.22186408.
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Affiliation(s)
- Lauren Tabor Gray
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Center for Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL
| | - Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
| | | | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville
| | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Neurology, University of Florida, Gainesville
- Department of Surgery, University of Florida, Gainesville
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Correlation of weight and body composition with disease progression rate in patients with amyotrophic lateral sclerosis. Sci Rep 2022; 12:13292. [PMID: 35918363 PMCID: PMC9345931 DOI: 10.1038/s41598-022-16229-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/06/2022] [Indexed: 11/08/2022] Open
Abstract
This study aims to observe the nutritional status of Chinese patients with amyotrophic lateral sclerosis (ALS), further investigating its effect on disease progression. One hundred consecutive newly diagnosed ALS patients and fifty controls were included. Weight and body composition were measured by bioelectrical impedance analysis at baseline and follow-ups. The revised ALS functional rating scale (ALSFRS-R) was used to calculate the rate of disease progression. Patients with ALS had a significantly lower BMI than controls, while no significant difference was found in body composition. Weight loss occurred in 66 (66%) and 52 (67.5%) patients at diagnosis and follow-up, respectively. Patients with significant weight loss (≥ 5%) at diagnosis had significantly lower BMI, fat mass (FM), and FM in limbs and trunk than those without. Fat-free mass (FFM), FM, and FM in limbs were significantly decreased along with weight loss at follow-up (p < 0.01). Patients with lower visceral fat index, lower proportion of FM, and higher proportion of muscle mass at baseline progressed rapidly during follow-ups (p < 0.05). Multivariate linear regression showed that FFM and weight at follow-up were independently correlated with disease progression rate at follow-up (p < 0.05). Weight loss is a common feature in ALS patients, along with muscle and fat wasting during the disease course. Body composition may serve as a prognostic factor and provide guidance for nutritional management in ALS patients.
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Manera U, Solero L, Fournier CN, Canosa A, Vasta R, Bombaci A, Grassano M, Palumbo F, Torrieri MC, Salamone P, Casale F, Fuda G, Moglia C, Calvo A, Chiò A. Validation of the Italian version of the Rasch-Built Overall Amyotrophic Lateral Sclerosis Disability Scale (ROADS) administered to patients and their caregivers. Amyotroph Lateral Scler Frontotemporal Degener 2021; 23:424-429. [PMID: 34894916 DOI: 10.1080/21678421.2021.2013892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Introduction: The Amyotrophic Lateral Sclerosis (ALS) functional rating scale - revised (ALSFRS-R) is the most widely used tool for the clinical monitoring in ALS patients. Despite his usefulness as a multidimensional scale, the combined score derived from different domains is not linearly related to symptoms severity. The Rasch-Built Overall ALS Disability Scale (ROADS) has recently been developed to overcome some of these limitations. Objectives: To validate the Italian version of the ROADS scale and assess the reliability of its administration to patients versus their respective caregivers and the correlation to the corresponding ALSFRS-R. Methods: In the Turin ALS Center, the ROADS Scale questionnaire was administered together with ALSFRS-R to 55 ALS patients and their caregivers during regular follow-up assessments. Correlation analysis was performed using Spearman's rho, Bland-Altman difference plots, Cronbach's alpha coefficient and Intraclass correlation coefficient (ICC), one-way random effects were used for proper comparison. Results: Their correlation coefficient between patients and caregivers ROADS was found to be very high (ICC 0.95, p < 0.001). Stratifying for age, sex, site of onset, type of caregiver, disease duration, and progression rate, ICC values that did not change significantly among the considered categories. We also found a high correlation between ROADS and ALSFRS-R total score (patients' correlation coefficient: 0.88). Conclusions: The Italian version of the ROADS scale is a valid and reliable tool to monitor disease burden, showing a high level of agreement between the responses given by patients and caregivers.
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Affiliation(s)
- Umberto Manera
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy.,SC Neurologia 1U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Luca Solero
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Christina Nicole Fournier
- Department of Neurology Emory University, Atlanta, GA, USA.,Department of Neurology, Atlanta VA Medical Center, Atlanta, GA, USA
| | - Antonio Canosa
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy.,SC Neurologia 1U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Rosario Vasta
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Alessandro Bombaci
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Maurizio Grassano
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Francesca Palumbo
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Maria Claudia Torrieri
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Paolina Salamone
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Federico Casale
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Giuseppe Fuda
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy
| | - Cristina Moglia
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy.,SC Neurologia 1U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Andrea Calvo
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy.,SC Neurologia 1U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Adriano Chiò
- ALS Centre, "Rita Levi Montalcini" Department of Neuroscience, University of Torino, Turin, Italy.,SC Neurologia 1U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
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Heiman-Patterson TD, Khazaal O, Yu D, Sherman ME, Kasarskis EJ, Jackson CE. Pulmonary function decline in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:54-61. [PMID: 34348540 DOI: 10.1080/21678421.2021.1910713] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: There has been no comprehensive longitudinal study of pulmonary functions (PFTS) in ALS determining which measure is most sensitive to declines in respiratory muscle strength. Objective: To determine the longitudinal decline of PFTS in ALS and which measure supports Medicare criteria for NIV initiation first. Methods: Serial PFTs (maximum voluntary ventilation (MVV), maximum inspiratory pressure measured by mouth (MIP) or nasal sniff pressure (SNIP), maximum expiratory pressure (MEP), and Forced Vital Capacity (FVC)) were performed over 12 months on 73 ALS subjects to determine which measure showed the sentinel decline in pulmonary function. The rate of decline for each measure was determined as the median slope of the decrease over time. Medicare-based NIV initiation criteria were met if %FVC was ≤ 50% predicted or MIP was ≤ 60 cMH2O. Results: 65 subjects with at least 3 visits were included for analyses. All median slopes were significantly different than zero. MEP and sitting FVC demonstrated the largest rate of decline. Seventy subjects were analyzed for NIV initiation criteria, 69 met MIP criteria first; 11 FVC and MIP criteria simultaneously and none FVC criteria first. Conclusions: MEP demonstrated a steeper decline compared to other measures suggesting expiratory muscle strength declines earliest and faster and the use of airway clearance interventions should be initiated early. When Medicare criteria for NIV initiation are considered, MIP criteria are met earliest. These results suggest that pressure-based measurements are important in assessing the timing of NIV and the use of pulmonary clearance interventions.
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Affiliation(s)
| | - Ossama Khazaal
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Daohai Yu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Michael E Sherman
- Department of Medicine, MCG-Hearst Health, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Edward J Kasarskis
- Department of Neurology, University of Kentucky, Lexington, KY, USA, and
| | - Carlayne E Jackson
- Department of Neurology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Prognostic role of slow vital capacity in amyotrophic lateral sclerosis. J Neurol 2020; 267:1615-1621. [DOI: 10.1007/s00415-020-09751-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/03/2020] [Accepted: 02/05/2020] [Indexed: 12/11/2022]
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